PROJECT SUMMARY The number of childhood cancer survivors in the United States is increasing each year. It is estimated there will be 500,000 childhood cancer survivors by the year 2020. Childhood cancer survivors are at an increased risk of developing chronic health conditions, in part, due to their previous cancer treatment. They develop these conditions at younger ages and at higher rates than the general population. The leading cause of non-cancer morbidity and mortality in childhood cancer survivors is cardiovascular disease (CVD). Strong evidence supports that a healthy diet, such as the Dietary Approaches to Stop Hypertension (DASH) and prudent pattern diet, lowers the risk of CVD in the general population, suggesting diet should be a priority area for CVD management and prevention in the general population. However, it is unknown whether diet has similarly beneficial effects in childhood cancer survivors who are at high risk for CVD. Few studies have examined the relation of diet to any adverse health outcomes in childhood cancer survivors. Most of these were small, evaluated nutritional status only, or focused on adolescents or young adults, rather than long-term aging adult survivors of childhood cancer. To close this knowledge gap in our understanding of the role of diet in CVD in adult survivors of childhood cancer, we propose to investigate whether dietary patterns are associated with the risk of CVD in the St. Jude Lifetime Cohort Study (SJLIFE). SJLIFE is a retrospective cohort study of long-term survivors of childhood cancer with prospective lifetime follow-up. The study collected participants' sociodemographic, health behavior, and medical history and cancer treatment data from medical records. Diet is assessed using a food frequency questionnaire. Participants also undergo comprehensive medical examinations at St. Jude Children's Research Hospital for assessment of health conditions, including CVD. We will examine two dietary patterns that are complementary to each other: 1) DASH score based on the adherence to a set of dietary recommendations proven to lower blood pressure and related to lower risk of CVD in the general population; and 2) study-specific dietary patterns derived by factor analysis that may identify childhood cancer survivor-specific dietary patterns. We will derive and characterize two dietary patterns ? DASH diet and study-specific dietary patterns (Aim 1); assess the relationship between dietary patterns and CVD risk (Aim 2); and investigate the association between dietary patterns and risk of CVD in high- and low- underlying CVD risk groups. Our study will provide much-needed information regarding the magnitude of impact of a healthy diet on CVD risk, and characteristics of survivors who may benefit from dietary intervention. Moreover, our study will significantly contribute to the development of new CVD prevention strategies and evidence- and risk-based dietary recommendations for childhood cancer survivors, which will guide clinicians and survivors on maintaining their health and quality of life.